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Quality of the electronic medical record

Kelly Claire Simon, Chad Yucus, James Castle, Richard Chesis, Rebekah Lai, Laura Hillman, Samuel Tideman, Lisette Garduno, Steven Meyers, Roberta Frigerio, Demetrius M Maraganore
The electronic medical record (EMR) presents an opportunity to standardize patient data collection based on quality guidelines and conduct practice-based research. We describe the development of a customized EMR "toolkit" that standardizes patient data collection with hundreds of discrete fields that supports Best Practices for treating patients with memory disorders. The toolkit also supports practice-based research. We describe the design and successful implementation of a customized EMR toolkit to support Best Practices in the care of patients with memory disorders...
2019: Frontiers in Neurology
Gregory L Alexander, Kimberly Powell, Chelsea B Deroche, Lori Popejoy, Abu Saleh Mohammad Mosa, Richelle Koopman, Lorren Pettit, Michelle Dougherty
OBJECTIVES: We describe the development of a nursing home information technology (IT) maturity model designed to capture stages of IT maturity. MATERIALS AND METHODS: This study had 2 phases. The purpose of phase I was to develop a preliminary nursing home IT maturity model. Phase II involved 3 rounds of questionnaires administered to a Delphi panel of expert nursing home administrators to evaluate the validity of the nursing home IT maturity model proposed in phase I...
March 19, 2019: Journal of the American Medical Informatics Association: JAMIA
Jodi K Jackson, Elizabeth Wickstrom, Betsi Anderson
OBJECTIVE: Develop a program that built a multidisciplinary, consensus-driven, evidence-based approach to oxytocin use, while adhering to national guidelines. DESIGN: This was a quality improvement project that used the Plan Do Study Act method to create cycles of change over several years. To initiate discussion, a survey was administered at a social event for providers from divergent community practices that addressed the controversial aspects of oxytocin use...
March 18, 2019: MCN. the American Journal of Maternal Child Nursing
Nicole Agaronnik, Eric G Campbell, Julie Ressalam, Lisa I Iezzoni
BACKGROUND: Patient-centered care for people with disability requires effective communication and compliance with the Americans with Disabilities Act (ADA). OBJECTIVE: To understand physicians' perspectives on communication experiences with people with disability. DESIGN: Twenty semi-structured individual interviews. Interview recordings were transcribed verbatim for analysis. SETTING: Massachusetts, October 2017-January 2018...
March 18, 2019: Journal of General Internal Medicine
Vijay A Patel, Jonathan A Harounian, Michele M Carr
The "Clinical Practice Guideline: Tympanostomy Tubes in Children" published in 2013 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation encourages that an "educational video, or other teaching aid, should be developed to illustrate how parents/caregivers" may manage postoperative complications such as tube otorrhea; however, the current literature is devoid of such patient safety and quality improvement measures. Our objective was to develop an effective educational model to assist parents and caregivers in understanding the signs and symptoms of tympanostomy tube (TT) otorrhea and how to independently institute the appropriate otologic treatment...
February 2019: Ear, Nose, & Throat Journal
Carly Daley, Tammy Toscos, Michael Mirro
The prevalence of cardiovascular implantable electronic devices with remote monitoring capabilities continues to grow, resulting in increased volume and complexity of biomedical data. These data can provide diagnostic information for timely intervention and maintenance of implanted devices, improving quality of care. Current remote monitoring procedures do not utilize device diagnostics to their potential, due to the lack of interoperability and data integration among proprietary systems and electronic medical record platforms...
March 17, 2019: Bioengineering
Susan M Shortreed, Andrea J Cook, R Yates Coley, Jennifer F Bobb, Jennifer C Nelson
Methodological advancements in epidemiology, biostatistics, and data science have strengthened the research world's ability to use data captured from electronic health records (EHRs) to address pressing medical questions, but gaps remain. We describe methods investments that are needed to curate EHR data toward research quality and to integrate complementary data sources when EHR data alone are insufficient for research goals. We highlight new methods and future directions for improving the integrity of medical evidence generated from pragmatic trials, observational studies, and predictive modeling...
March 16, 2019: American Journal of Epidemiology
Patrick A Eder, Birgit Reime, Thomas Wurmb, Uwe Kippnich, Layal Shammas, Asarnusch Rashid
BACKGROUND:  Trauma is a global burden. Emergency medical services (EMS) provide care for individuals who have serious injuries or suffered a major trauma. OBJECTIVE:  This paper provides a comprehensive overview of telemedicine applications in prehospital trauma care. METHODS:  We conducted a systematic review according to PRISMA guidelines. We identified articles by electronic database search (PubMed, EMBASE, the Cochrane Library, CINAHL, SpringerLink, LIVIVO, DARE, IEEE Xplore, Google Scholar and ScienceDirect) using keywords related to prehospital settings, ambulance, telemedicine and trauma...
November 2018: Methods of Information in Medicine
Gavin Tsang, Xianghua Xie, Shangming Zhou
Dementia is a chronic and degenerative condition affecting millions globally. The care of patients with dementia presents an ever continuing challenge to healthcare systems in the 21st century. Medical and health sciences have generated unprecedented volumes of data related to health and wellbeing for patients with dementia due to advances in information technology, such as genetics, neuroimaging, cognitive assessment, free texts, routine electronic health records etc. Making the best use of these diverse and strategic resources will lead to high quality care of patients with dementia...
March 12, 2019: IEEE Reviews in Biomedical Engineering
Joanna Paladino, Rachelle Bernacki, Bridget A Neville, Jane Kavanagh, Stephen P Miranda, Marissa Palmor, Joshua Lakin, Meghna Desai, Daniela Lamas, Justin J Sanders, Jonathon Gass, Natalie Henrich, Stuart Lipsitz, Erik Fromme, Atul A Gawande, Susan D Block
Importance: Earlier clinician-patient conversations about patients' values, goals, and preferences in serious illness (ie, serious illness conversations) are associated with better outcomes but occur inconsistently in cancer care. Objective: To evaluate the efficacy of a communication quality-improvement intervention in improving the occurrence, timing, quality, and accessibility of documented serious illness conversations between oncology clinicians and patients with advanced cancer...
March 14, 2019: JAMA Oncology
Sara H Katsanis, Elaine Huang, Amanda Young, Victoria Grant, Elizabeth Warner, Sharon Larson, Jennifer K Wagner
OBJECTIVE: Healthcare providers have key roles in the prevention of, detection of, and interventions for human trafficking. Yet caring for trafficked persons is particularly challenging: patients whose identities are unknown, unreliable, or false could receive subpar care from providers delivering care in a vacuum of relevant information. The application of precision medicine principles and integration of biometric data (including genetic information) could facilitate patient identification, enable longitudinal medical records, and improve continuity and quality of care for this vulnerable patient population...
2019: PloS One
Sarah Zheng, Amresh Hanchate, Michael Shwartz
BACKGROUND: To overcome the limitations of administrative data in adequately adjusting for differences in patients' risk of readmissions, recent studies have added supplemental data from patient surveys and other sources (e.g., electronic health records). However, judging the adequacy of enhanced risk adjustment for use in assessment of 30-day readmission as a hospital quality indicator is not straightforward. In this paper, we evaluate the adequacy of risk adjustment by comparing the one-year costs of those readmitted within 30 days to those not after excluding the costs of the readmission...
March 12, 2019: BMC Health Services Research
R Ryanne Wu, Rachel A Myers, Adam H Buchanan, David Dimmock, Kimberly G Fulda, Irina V Haller, Susanne B Haga, Melissa L Harry, Catherine McCarty, Joan Neuner, Teji Rakhra-Burris, Nina Sperber, Corrine I Voils, Geoffrey S Ginsburg, Lori A Orlando
OBJECTIVE:  Investigate sociodemographic differences in the use of a patient-facing family health history (FHH)-based risk assessment platform. METHODS:  In this large multisite trial with a diverse patient population, we evaluated the relationship between sociodemographic factors and FHH health risk assessment uptake using an information technology (IT) platform. The entire study was administered online, including consent, baseline survey, and risk assessment completion...
March 2019: Applied Clinical Informatics
Young-Shin Lee, Eun-Ju Choi, Yeon-Hee Kim, Hyeoun-Ae Park
OBJECTIVE: The purpose of this study was to explore the characteristics and predictors of falls in high- and low-risk inpatients in a tertiary hospital in Korea. METHODS: Fallers' data were extracted from quality improvement reports and electronic health records from June 1, 2014, to May 31, 2015. Data on nonfallers matched by the length of hospitalization and medical departments of fallers were extracted from electronic health records. Participants were classified into a high- or a low-risk group based on their Morse Fall Scale score, fall risk-related symptoms, and medications known to increase fall risk...
March 8, 2019: Journal of Patient Safety
Dursun Delen, Behrooz Davazdahemami, Enes Eryarsoy, Leman Tomak, Abhinav Valluru
Epilepsy is one of the most common brain disorders that greatly affects patients' quality of life and poses serious risks to their health. While the majority of the patients positively respond to the existing anti-epilepsy drugs, others who developed the refractory type of epilepsy show resistance against drug therapy and need to undergo advance treatments such as surgery. Given that identifying such patients is not a straightforward process and requires long courses of trial and error with anti-epilepsy drugs, this study aims at predicting those at-risk patients using clinical and demographic data obtained from electronic medical records...
March 12, 2019: Health Informatics Journal
Claire E Kendall, Esther S Shoemaker, Janessa E Porter, Lisa M Boucher, Lois Crowe, Ron Rosenes, Christine Bibeau, Philip Lundrigan, Marissa L Becker, Shabnam Asghari, Sean B Rourke, Clare Liddy
PURPOSE: For people living with HIV (PLWH) using continuous antiretroviral therapy, HIV is now a complex chronic condition often managed in primary care settings. The patient-centered medical home (PCMH) is a model to deliver comprehensive, coordinated, and integrated primary care that promotes collaboration between primary and specialist care and allied services. The study assessed how both Canadian primary and specialist HIV care settings align with the PCMH. METHODS: Mixed-methods surveys and interviews with providers in Canadian HIV care settings...
March 2019: Journal of the American Board of Family Medicine: JABFM
Lauren A Heidemann, Danielle L Heidemann, Amanda Huey, Melanie Dalton, Sarah Hartley
Construct: We aimed to develop an assessment tool to measure the quality of electronic health record inpatient documentation of cross-cover events. BACKGROUND: Cross-cover events occur in hospitalized patients when the primary team is absent. Documentation is critical for safe transitions of care. The quality of documentation for cross-cover events remains unknown, and no standardized tool exists for assessment. APPROACH: We created an assessment tool for cross-cover note quality with content validation based on input from 15 experts...
March 8, 2019: Teaching and Learning in Medicine
Francis Fatoye, Tadesse Gebrye, Isaac Odeyemi
Low back pain (LBP) is a common health problem among adults of working age population, and its prevalence or incidence increases with increasing in age. The purpose of this review was to examine the real-world prevalence or incidence of LBP. A systematic review of the literature was conducted in accordance to the PRISMA guideline. Allied and Complementary Medicine Database, Cumulative Index of Nursing and Allied Health Literature, MEDLINE, SportDiscuss and Scopus electronic databases were searched using specifically developed search strategies to identify studies using patients' electronic medical records published in English up to February 2019...
March 8, 2019: Rheumatology International
Francis Deng, Matthew D Li, Adrian Wong, Leigh T Kowalski, Kenneth H Lai, Subba R Digumarthy, Li Zhou
PURPOSE: To describe and appraise contrast agent allergy documentation in the electronic health record (EHR). METHODS: We systematically identified medical imaging drugs and class terms in an integrated EHR allergy repository for patients seen at a large health care system between 2000 and 2013. Structured and free-text contrast allergy records were normalized and categorized by inciting agent and nature of adverse reaction. Allergen records were evaluated by their level of specificity...
March 4, 2019: Journal of the American College of Radiology: JACR
Ashley M Cooper, Mara Horwitz, Mara L Becker
OBJECTIVES: Although teratogenic medications are commonly used to treat rheumatic disease, no standard model currently exists for educating adolescent patients about teratogenic risk or performing routine pregnancy screening. We performed a quality improvement project to increase education and pregnancy screening in girls and women of childbearing age prescribed teratogenic medications in our pediatric rheumatology clinic. METHODS: Eligible participants included female patients age 10 and older prescribed teratogenic medications in a single-center tertiary care pediatric rheumatology clinic...
March 5, 2019: Pediatrics
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